Fixed combination with albuterol sulfate is used for the symptomatic management of bronchospasm associated with COPD in patients who continue to have evidence of bronchospasm despite the regular use of an orally inhaled bronchodilator and who require a second bronchodilator.320347

May be useful as alternative therapy in adults experiencing adverse effects (e.g., tachycardia, arrhythmia, tremor) with a β-adrenergic agonist†.331336337

Some clinicians consider ipratropium as adjunctive therapy in patients with moderate or severe exacerbations (peak expiratory flow rate ≤80% of predicted) of asthma† who fail to respond adequately to β-adrenergic agonists and corticosteroids.331337

May be useful for prevention or reversal of bronchospasm induced by β-adrenergic blocking agents† (e.g., propranolol) in asthmatic patients; β-adrenergic bronchodilators generally ineffective for this indication in such patients.31191194225268

Atrovent Dosage and Administration

Administration

Administer by oral inhalation using an oral aerosol inhaler110320 or via nebulization.4281329

Exhale slowly and completely and place the mouthpiece of the inhaler well into the mouth with the lips closed around it.10348 To avoid contact of the drug with the eyes and subsequent adverse effects, close eyes during inhalation of aerosol.110348 Inhale slowly and deeply through the mouth while actuating the inhaler.110 Hold the breath for 10 seconds, withdraw the mouthpiece, and exhale slowly.110

Allow ≥15 seconds to elapse between subsequent inhalations from the aerosol inhaler.10348

Wash the mouthpiece in hot running water as needed.10348 If soap is used, rinse mouthpiece thoroughly with plain water.10348

Ipratropium Bromide and Albuterol Sulfate

Shake well immediately prior to use.346 Actuate 3 times prior to the initial use or if it has not been used for >24 hours.346 Do not use actuator provided for other aerosol drugs.346 To avoid contact of the drug with the eyes and subsequent adverse effects, close eyes during inhalation of aerosol.346

Exhale deeply and place mouthpiece of the inhaler into the mouth.346 Inhale slowly and deeply through the mouth while actuating the inhaler.346 Hold the breath for 10 seconds, withdraw the mouthpiece, and exhale slowly.346 Allow approximately 2 minutes to elapse and repeat the procedure.346 Rinse the mouthpiece in hot water as needed.346 If soap is used, rinse the mouthpiece thoroughly with plain water.346 When dry, replace the cap on the mouthpiece when the inhaler is not in use.346

Oral Inhalation via Nebulization

Ipratropium Bromide

Empty entire contents of the single-use vial of solution into the nebulizer reservoir and attach reservoir to the mouthpiece or face mask and to the compressor according to the manufacturer’s instructions.4328350

Use care when a face mask is used to avoid leakage since transient blurred vision and other adverse effects may result if the drug enters the eyes.2225250275328350 (See Ocular Effects under Cautions.) Use of a mouthpiece may avoid inadvertent entry of drug into the eye.4

Place the mouthpiece of the nebulizer in the mouth or put on the nebulizer face mask.415328 Breathe as calmly, deeply, and evenly as possible until the nebulizer stops producing mist.4328

Ipratropium Bromide and Albuterol Sulfate

Empty entire contents of the single-use vial of solution into the nebulizer reservoir and attach reservoir to the mouthpiece or face mask and to the compressor according to the manufacturer’s instructions.328

Place the mouthpiece of the nebulizer in the mouth or put on the nebulizer face mask.328 Breathe as calmly, deeply, and evenly as possible until the nebulizer stops producing mist.328

Clean the nebulizer after use according to the manufacturer’s instructions.328

Dosage

Available as ipratropium bromide.

Dosage of oral inhalation aerosol expressed in terms of the monohydrate.1320

Dosage of inhalation solution for nebulization expressed in terms of anhydrous drug.4329330

Using in vitro testing at an average flow rate of 3.6 L per minute for an average of ≤15 minutes, the Pari-LC Plus nebulizer delivered at the mouthpiece approximately 46 or 42% of the original dosage of albuterol or ipratropium bromide, respectively.327

General Precautions

Worsening COPD

Contact a clinician immediately if a previously effective dosage regimen fails to provide the usual relief (e.g., need to increase the dose or frequency of administration of the drug).1 Do not increase the dose or frequency of inhalation without consultation with a clinician.1

Ocular Effects

Possible temporary blurred vision,12410328349 mydriasis,1225250275 ocular pain,4328329349 conjunctival or corneal congestion associated with visual halos or colored images,1 or precipitation or worsening of angle-closure glaucoma4173329337349 following inadvertent contact of ipratropium with the eyes.4190191328349

Minimize ocular exposure by using a mouthpiece rather than a face mask during administration via a nebulizer.4190191329 During oral inhalation of aerosol, close eyes.12 Inhalation aerosol should not be administered using the open-mouth technique in these patients with angle-closure glaucoma.173190191 Use with caution in patients with angle-closure glaucoma.14

Plasma Protein Binding

Elimination

Metabolism

Elimination Route

Excreted principally in feces as unchanged drug.2367107109 Following oral inhalation of radiolabeled ipratropium bromide, about 69 and 3.2% of the dose was excreted in feces and urine, respectively, within 6–7 days.6106109 Undergoes some biliary elimination.67

Advice to Patients

Importance of advising patients that oral inhalation is not intended for occasional use.14 Use consistently throughout the course of therapy for maximum effectiveness.14

Importance of contacting a clinician if symptoms of COPD are not relieved by usually effective doses or if they worsen.1 Do not increase the dosage or frequency of administration without consultation with a clinician.1

Importance of advising patients to close their eyes during oral inhalation of aerosol12 to avoid inadvertent contact of the drug with the eyes and subsequent adverse effects.110

Importance of contacting a clinician immediately if ocular symptoms develop.1

Importance of advising patients that blurring of vision, precipitation or aggravation of narrow angle glaucoma, mydriasis, visual halos, colored images in association with conjunctival or corneal congestion, or eye pain or discomfort may result from contact of the inhalation solution with the eyes.1

8. Deckers W. The chemistry of new derivatives of tropane alkaloids and the pharmacokinetics of a new quaternary compound. Postgrad Med J. 1975; 51(Suppl 7):76-81. http://www.ncbi.nlm.nih.gov/pubmed/134360?dopt=AbstractPlus

161. National Asthma Education Program, National Institutes of Health. Executive summary: guidelines for the diagnosis and management of asthma. US Department of Health and Human Services, Public Health Service, National Institutes of Health. Publication No.. 94-3042A. 1994 Jul.

343. ATS/ERS Standards for the diagnosis and management of patients with COPD. New York, NY: American Thoracic Society, European Respiratory Society; 2004. Available from website. Accessed Dec. 8, 2004. http://www.thoracic.org/clinical/copd-guidelines

345. Celli BR, Macnee W. Standard for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. Eur Respir J. 2004; 23:932-46. http://www.ncbi.nlm.nih.gov/pubmed/15219010?dopt=AbstractPlus